West Virginia Children s Health Insurance Program

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Sophie Hancock
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1 West Virginia Children s Health Insurance Program (WVCHIP) Jennifer J Myers, Benefit and Enrollment Specialist Spring 2016 Provider Workshop

2 Reside in West Virginia Are under age 19 Eligibility Children are eligible if they: Are not eligible for West Virginia Medicaid and are not covered under any other creditable coverage Income and family size fall within qualifying Income Guidelines Are United States citizens or qualified aliens 1

3 Income Guidelines Annual Income Guidelines for WVCHIP: Family Size Medicaid Max WVCHIP Gold WVCHIP Blue WVCHIP Premium 2 $21,307 $24,030 $33,803 $48,060 3 $26,813 $30,240 $42,538 $60,480 4 $32,319 $36,450 $51,273 $72,900 5 $37,826 $42,660 $60,009 $85,320 6 $43,332 $48,870 $68,744 $97,740 2

4 Coverage 3

5 Claim Submissions Pharmacy claims will processed by Express Scripts through 6/30/2016. Pharmacy claims after 7/1/2016 will be processed by CVS. Medical/Dental claims date of service prior to 12/31/2015 submit to: HealthSmart Benefit Solutions PO Box 2451 Charleston, WV Medical/Dental claims date of service 1/1/2016 and after submit to: Molina Medicaid Solutions PO Box 3732 Charleston, WV

6 Provider Enrollment The Affordable Care Act requires all providers to enroll or revalidate their enrollment information under new enrollment screening criteria. Enrollment and revalidation is mandatory for both Medicaid and WVCHIP providers. Any provider that has revalidated with Medicaid has been provisionally enrolled with WVCHIP. Full enrollment will be required by June 30, If you have not begun the provider enrollment process, contact Molina at , or , as soon as possible. 5

7 Out-of-State Providers WVCHIP does not cover services provided out-of-state that are available from in-state providers, except for emergencies and office visits to primary care physicians (family and general medicine physicians, internists, and pediatricians) in counties bordering West Virginia in surrounding states. (Routine childhood vaccines from outof-state providers, including border providers, are not covered routine childhood vaccines are covered when received from in-state Vaccine for Children s program (VFC) providers.) There are exceptions for medical necessity and emergencies. To meet the criteria as a covered benefit, the service must be medically necessary, and the type of care must not be available within the State of West Virginia, as determined PRIOR to the service. 6

8 Out-of-State Providers (cont.) WVCHIP will waive the out-of-state prior authorization requirement if the provider agrees to accept WVCHIP in-state fees as payment in full with no balance billing to the member. This agreement can be made during provider enrollment. WVCHIP uses the Public Employees Insurance Agency s fees. These can be found on their website, Dental fees can be found at: You may also send an inquiry to WVCHIPProvider@Outlook.com. 7

9 Orthodontic Treatment Comprehensive orthodontic treatment is payable once per lifetime. Coverage is not automatic and must meet certain criteria and be prior authorized to be covered. Information should be mailed to: WVCHIP Orthodontic PA Request 2 Hale Street, Suite 101 Charleston, WV Information required for review: Panoramic Film Cephalometric Xray A standard series of 5 Intra and 3 Extra Oral photographs that meet the American Board of Orthodontic standards Treatment Plan including findings, prognosis, length of treatment, and phases of treatment 8

10 Resources For eligibility, application status, renewals and general information: WVCHIP HelpLine at Health claims and benefits, and eligibility prior to 1/1/2016: HealthSmart at Health claims and benefits, and eligibility after 1/1/2016: Molina at or Prior-authorizations: HealthSmart at Prescription drug benefits: Express Scripts at Provider enrollment: Molina Medicaid Solutions at

11 Claim Submissions Common errors on claim submissions: All claims should be submitted using the member s ten digit ID number. On paper claims the ICD9/10 indicator should be 0. All claims and correspondence should include you NPI number. WVCHIP has only one mail box for all claim types. 10

12 Contact Jennifer J. Myers Benefit and Enrollment Specialist WVCHIP 2 Hale Street Charleston, WV Phone: Fax: Jennifer.J.Myers@wv.gov Follow WV DHHR on Facebook and Twitter for WVCHIP related announcements and information. 11

WV CHILDREN S HEALTH INSURANCE PROGRAM

WV CHILDREN S HEALTH INSURANCE PROGRAM Jennifer Myers, Benefit and Enrollment Specialist, What is? was created to help working families who do not have health insurance for their children. In 1997 Congress